Topical Dermatologic Therapies Basic Dermatology Curriculum

Last updated January 2016

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Module Instructions  The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated guide to clinical dermatology and dermatopathology.  We encourage the learner to read all the hyperlinked information.

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Goals and Objectives  The purpose of this module is to help learners gain familiarity with common dermatologic treatments  By completing this module, the learner will be able to: • Estimate the amount of topical medication needed for therapy based on frequency of application and body surface area involved • Match individual topical steroids to their potency class • Choose appropriate strengths of topical steroids based on age, body location and severity of dermatitis • List side effects of prolonged use of topical steroids • Discuss the basic principles of common topical medications used to treat acne, superficial fungal infections and psoriasis

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Principles of Dermatologic Therapy  The efficacy of any topical medication is related to: • Active ingredient (inherent strength) • Anatomic location • Vehicle (the mode in which it is transported) • Concentration of the medication

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Vehicles Foams Gels

Creams

Sprays Oils

Solutions

Ointments

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Vehicles  Ointments (e.g., Vaseline): lubricating, semiocclusive, greasy, does not sting • Useful for smooth, non-hairy skin; dry, thick, or hyperkeratotic lesions

 Creams (vanish when rubbed in): less greasy, not occlusive, may sting, could cause irritation (preservatives/fragrances) • Useful for acute exudative inflammation, intertriginous areas (when skin is in contact with skin, e.g., armpits, groin, pannus)

 Lotion (pourable liquid): less greasy, less occlusive, may sting • Helpful for acute exudative inflammation (e.g., acute contact dermatitis) and on hairy areas

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Vehicles  Oils: less stinging, keratolytic (removes scale) • Useful for the scalp, especially for people with coarse or very curly hair

 Gel (jelly-like): may sting, greaseless, least occlusive, dry quickly • Useful for acne and on scalp/hairy areas without matting

 Foams (cosmetically elegant): spread readily, easier to apply, more expensive • Useful for hairy areas and inflamed skin

 Sprays: aerosols (rarely used), pump sprays 7

Medication Costs  Topical medications can be very expensive  They are not all covered by insurance  Over the counter (OTC) treatments are generally cheaper than prescriptions  Generics are usually less expensive than brand name prescriptions  It is helpful to know the costs of the medications prescribed and be able to tell the patient in advance what they should expect to pay

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Topical Prescriptions  Patient vehicle preference, cost and availability determine their selection  What goes into a topical prescription? • Desonide cream 0.05% apply a thin layer to affected area (face) BID PRN for red, itchy skin #60 grams refills 3

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Topical Prescriptions  What goes into a prescription? • Desonide cream 0.05% apply a thin layer to affected area (face) BID PRN for red, itchy skin #60 grams refills 3 • Generic name

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Topical Prescriptions  What goes into a prescription? • Desonide cream 0.05% apply a thin layer to affected area (face) BID PRN for red, itchy skin #60 grams refills 3 • Generic name • Vehicle

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Topical Prescriptions  What goes into a prescription? • Desonide cream 0.05% apply a thin layer to affected area (face) BID PRN for red, itchy skin #60 grams refills 3 • Generic name • Vehicle • Concentration

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Topical Prescriptions  What goes into a prescription? • Desonide cream 0.05% apply a thin layer to affected area (face) BID PRN for red, itchy skin #60 grams refills 3 • Generic name • Vehicle • Concentration • Sig (directions)

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Topical Prescriptions  What goes into a prescription? • Desonide cream 0.05% apply a thin layer to affected area (face) BID PRN for red, itchy skin #60 grams refills 3 • Generic name • Vehicle • Concentration • Sig • Amount

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Topical Prescriptions  What goes into a prescription? • Desonide cream 0.05% apply a thin layer to affected area (face) BID PRN for red, itchy skin #60 grams refills 3 • Generic name • Vehicle • Concentration • Sig • Amount • Refills

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Let’s Review Some Common Types of Topical Medications Used by Dermatologists

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Topical Corticosteroids  Topical corticosteroids steroids produce an anti-inflammatory response in the skin  They are used to treat many dermatological conditions, including atopic dermatitis and psoriasis  They also provide symptomatic relief for burning and pruritic lesions

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Topical Corticosteroids  Topical corticosteroids are organized into classes based on their strength (potency), ranging from super high potency (class I) to low potency (class VII) • Steroids within any class are equivalent in strength • Class one is about 1000 times more potent than hydrocortisone 1%

 Strength is inherent to the molecule, not the concentration

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Topical Corticosteroid Strength Potency Super high High

Medium

Low

Class

Example Agent

I

Clobetasol propionate cream 0.05%

II

Fluocinonide cream, ointment 0.05% Mometasone furoate ointment 0.1%

III – V

Mometasone furoate cream 0.1% Triamcinolone acetonide cream, ointment 0.1%

VI – VII

Fluocinolone acetonide cream 0.01% Desonide cream, ointment 0.05% Hydrocortisone cream, ointment 1% 19

Topical Corticosteroid Strength  Remember to look at the class not the percentage • Clobetasol 0.05% is much stronger than hydrocortisone 1%

 Note that mometasone ointment is high potency while mometasone cream is low potency because of the nature of the vehicle

Potency Super high

High

Class I

II

Example Agent Clobetasol propionate cream 0.05% Fluocinonide cream, ointment 0.05% Mometasone furoate ointment 0.1% Mometasone furoate cream 0.1%

Medium

III – V

Triamcinolone acetonide cream, ointment 0.1% Fluocinolone acetonide cream 0.01%

Low

VI – VII

Desonide cream, ointment 0.05% Hydrocortisone cream, ointment 1%

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Topical Corticosteroid Selection  Super high potency (class I) are used for severe dermatoses over nonfacial and nonintertriginous areas • Scalp, palms, soles, and thick plaques on extensor surfaces

 Medium to high potency steroids (classes II-V) are appropriate for mild to moderate nonfacial and nonintertriginous areas • Okay to use on flexural surfaces for limited periods

 Low potency steroids (classes VI, VII) can be used for large areas and on thinner skin • Face, eyelid, genital and intertriginous areas

 Know one steroid from each class that would be available to the majority of your patients

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Absorption  Topical corticosteroids are better absorbed through areas of inflammation and desquamation compared to normal skin  Absorbed more readily through thin stratum corneum of infants compared to adults  Anatomic regions with a thin epidermis are significantly (e.g., eyelid) more permeable then thick-skinned areas (e.g., palms)  Ointments allow better percutaneous drug absorption and are therefore more potent than creams or lotions 22

Local Cutaneous Side Effects  Local side effects of topical steroids include: • Skin atrophy • Telangiectasias • Striae

• Acne or rosacea-like eruption • Allergic contact dermatitis • Hypopigmentation

 The higher the potency the more likely side effects are to occur  To reduce risk, the least potent steroid should be used for the shortest time, while still maintaining effectiveness

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Local Cutaneous Side Effects Skin Atrophy

Striae

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Local Cutaneous Side Effects Hypopigmentation

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Systemic Side Effects  Systemic side effects from topical corticosteroids are rare due to low percutaneous absorption  They can include: • • • • •

Glaucoma Hypothalamic pituitary axis suppression Cushing’s syndrome Hypertension Hyperglycemia

 Exercise caution with widespread use and occlusive methods (e.g., plastic wrap, bandages)

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Treatment Duration  In general: • Super high potency: treat for